Currently long term care (LTC) is characterized by the rapid growth of a fragmented and costly "system" with substantial and persistent concerns about quality. Health related quality of life (HRQoL) has been identified by leading clinical scholars as a focal outcome for quality assessment among the growing population of elders receiving LTC in the U.S. Unfortunately there is a paucity of data regarding the trajectory of changes in the multiple domains reflecting HRQoL in this population. As a result, elders and their families have inadequate information upon which to assess the quality of various LTC options, and clinicians and policy makers do not have the knowledge base to assure high quality, cost-effective services. The proposed longitudinal study, designed to address these important gaps in knowledge, has three primary aims: (1) to examine the natural history of changes in each of the multiple domains of HRQoL (i.e. biological and physiological factors, symptom status, functional status, emotional status, behavioral status, general health perceptions and perceived overall quality of life) among elders newly admitted to one of three LTC options over a two year period; (2) to compare patterns of change in each of these domains across LTC options by examining these patterns among a matched sample of elders who remain in their respective LTC option for at least one year; and, (3) to evaluate causal relationships among multiple HRQoL domains and salient contextual factors including those reflecting facility structure and care process in order to provide an empirical basis for testing such relationships in future studies. Equally distributed throughout major providers of LTC, nursing homes (NHs), assisted living facilities (ALFs), and home and community-based services (H&CBS), a total of 468 consenting elders newly admitted to LTC will receive 9 interviews (baseline plus every 3 months through two years post-baseline) using a comprehensive set of valid and reliable instruments collectively called the HRQoL Assessment. Data related to the HRQoL domains and the structure and processes of care that may influence them will be generated through staff interviews, medical record abstractions, and facility surveys. For Aim 1, a naturalistic examination of two-year patient trajectories within LTC option will be conducted accounting for attrition over time using the 'pattern mixture' approach for missing data. Aim 2 analyses will focus on comparisons among LTC options in the distributions of changes in HRQoL domains from admission to months 6 and 12 among elders remaining in their respective LTC settings for at least one year using propensity modeling to adjust for selection bias. Aim 3 analyses will include applying causal analyses to evaluate the mediating and moderating effects of HRQoL domains across the causal chain that are implied by the underlying conceptual framework. Additional exploratory aims will guide analyses of the effects of structure and process of care on changes in HRQoL domains. This study will examine the natural history of changes in each of the multiple domains of HRQoL among elders newly admitted to one of three long term care options over a two year period. The findings from this study will enable policy makers and providers, as well as recipients of long term care services, to evaluate and make informed choices related to long-term care.